Directory of prescription drug patient assistance programs

99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page i 1999–2000
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page iii INTRODUCTION
The research-based pharmaceutical industry has had a long-standing tradition ofproviding prescription medicines free of charge to physicians whose patients mightnot otherwise have access to necessary medicines.
To make it easier for physicians to identify the growing number of programs availablefor needy patients, member companies of the Pharmaceutical Research andManufacturers of America (PhRMA) created this directory. It lists company programsthat provide drugs to physicians whose patients could not otherwise afford them.
The programs are listed alphabetically by company. Under the entry for each programis information about how to make a request for assistance, what prescriptionmedicines are covered, and basic eligibility criteria.
Common Questions About This Directory
Q. Who determines whether a medication is listed in the PhRMA Directory?
A. Pharmaceutical manufacturers who belong to PhRMA decide which medications
to list.
Q. What does it mean if this Directory does not list a medication?
A. If a particular medication is not listed, the drug may not be available under this
program or may not be manufactured by a company belonging to PhRMA. PhRMA
does not have access to information about indigent programs offered by non-member
companies.
Q. What are the eligibility criteria for the program? How does one apply?
A. Each company determines the eligibility criteria for its program. Eligibility criteria
and application processes vary. Basic eligibility criteria are listed in the directory. If
you do not find the answer to your question here, you should contact the drug
manufacturer directly. Telephone numbers are listed in the directory. For numbers of
companies not listed here, consult a Physician’s Desk Reference (PDR).
Q. Can PhRMA provide products directly to patients and/or health care providers?
A. Release of prescription drugs is subject to numerous federal and state laws.
PhRMA is not permitted to dispense or ship pharmaceutical products.
While these programs of America’s pharmaceutical research companies areindispensable for the neediest patients, they cannot be expected to solve the largernational problem of access to medical care, including prescription drugs. Thepharmaceutical industry will continue to work cooperatively with those seekingpublic and private sector solutions to these larger problems.
1999 Pharmaceutical Research and Manufacturers of America 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page v TABLE OF CONTENTS
Abbott Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Agouron Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1ALZA Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1Amgen Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2AstraZeneca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Bayer Corporation Pharmaceutical Division . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Biogen, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Boehringer Ingelheim Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Bristol-Myers Squibb Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Ciba Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6DuPont Pharmaceuticals Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Eisai Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Elan Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Fujisawa Healthcare, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Genentech, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Genetics Institute, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Genzyme Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Gilead Sciences, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Glaxo Wellcome Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Hoechst Marion Roussel, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Janssen Pharmaceutica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Knoll Pharmaceutical Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Lederle Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Eli Lilly and Company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12The Liposome Company, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Merck & Co., Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Novartis Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Ortho Biotech Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Ortho Dermatological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Ortho-McNeil Pharmaceutical, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Parke-Davis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Pasteur Mérieux Connaught . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Pfizer Inc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Pharmacia & Upjohn, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Procter & Gamble Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20Rhône-Poulenc Rorer Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Roche Laboratories, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Roxane Laboratories, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23Sandoz Pharmaceutical Corporation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Sanofi Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Schering Laboratories/Key Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24Searle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Serono Laboratories, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Sigma-Tau Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26SmithKline Beecham Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Solvay Pharmaceuticals, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283M Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Wyeth-Ayerst Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Zeneca Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 1 Eligibility
LABORATORIES
Name Of Program
case basis and takes into considerationan individual’s circumstances. Potential Physician Requests Should Be
Directed To
9am and 6pm EST. Applications aremailed to the physician’s office. Abbott LaboratoriesUninsured Patient Program Other Program Information
Product(s) Covered By Program
Depakote, Gabitril, Norvir and Biaxin(Biaxin program available to patients w/ ALZA PHARMACEUTICALS
Name Of Program
Eligibility
Abbott Laboratories uninsured patientprogram is available to outpatients who Physician Requests Should Be
Directed To
for prescriptions and are not eligible for Other Program Information
8990 Springbrook Drive, Suite 200Minneapolis, MN 55433 Abbott Laboratories to request anapplication on the behalf of a patient.
Product(s) Covered By Program
patient’s eligibility. If approved,medication will only be shipped to the Eligibility
Eligibility is determined by ALZAPharmaceuticals and is based on PHARMACEUTICALS, INC.
level. Patients must be ineligible forany other third-party reimbursement or Name Of Program
Indigent Patient Assistance Program.
Physician Requests Should Be
Other Program Information
Directed To
Product(s) Covered By Program
VIRACEPT® (nelfinavir mesylate)
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 2 AMGEN INC.
Eligibility
Name Of Program
For patients with chronic hepatitis Conly. Amgen’s SAFETY NET® Program Physician Requests Should Be
Directed To
based on patient’s insurance status andincome level. To enroll a patient, the Product(s) Covered By Program
Other Program Information
Eligibility
patient may enroll him or herself. Anyadministering physician, hospital, NET® Program by calling (800) 272-9376.
Other Program Information
Name Of Program
hospital or home dialysis supplier maysponsor a patient by applying to the Physician Requests Should Be
Directed To
year rather than on a calendar year.
Product(s) Covered By Program
Name Of Program
Eligibility
Physician Requests Should Be
Directed To
uninsured or underinsured). Eligibilityis based on patient’s insurance status Product(s) Covered By Program
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 3 Other Program Information
Other Program Information
physician’s office on the patient’s behalf ASTRAZENECA
Name Of Program
Name Of Program
Physician Requests Should Be
Directed To
Physician Requests Should Be
Directed To
Product(s) Covered By Program
Product(s) Covered By Program
2.5% and prilocaine 2.5% cream),EMLA® CREAM (lidocaine 2.5% and Eligibility
Eligibility
deductibles or maximum benefit limits.
Other Program Information
Referral must be made by the
physician.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 4 Name Of Program
Other Program Information
months. A reapplication is automaticallysent to enrolled patients. Patient/family Physician Requests Should Be
Directed To
Enrollment in the program requires avalid Social Security Number. In Product(s) Covered By Program
is required with each prescription for all (isosorbide dinitrate) Oral Tablets USP, SULAR® (nisoldipine) Tablets, BAYER CORPORATION
PHARMACEUTICAL
DIVISION
TENORMIN® (atenolol) Tablets, ZESTORETIC® (lisinopril and Name Of Program
ZESTRIL® (lisinopril) Tablets, ZOLADEX® (goserelin acetate Physician Requests Should Be
Directed To
Eligibility
a case-by-case basis by the ZenecaPharmaceuticals Foundation. Eligibility Product(s) Covered By Program
in a public program. Income eligibilityis based upon multiples of the U.S. poverty level adjusted forhousehold size.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 5 Eligibility
Physician Requests Should Be
Directed To
Physician must indicate condition forwhich drug is to be prescribed and Product(s) Covered By Program
agree to follow patient through therapy.
All applications are subject to a case-by- case evaluation by Bayer Corporation.
Other Program Information
Eligibility
physician’s office for signatures.
Other Program Information
BIOGEN, INC.
All requests are reviewed and approvedon a case-by-case basis. Application Name Of Program
form, prescription, and patient’s incomedocumentation are required. Maximum Physician Requests Should Be
Directed To
same year require only the applicationform and a prescription. Product(s) Covered By Program
Avonex® (interferon beta-1a)
Program is subject to change withoutnotice. Current program specifics can Eligibility
BRISTOL-MYERS SQUIBB
BOEHRINGER INGELHEIM
PHARMACEUTICALS, INC.
Name Of Program
Name Of Program
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 6 Physician Requests Should Be
Product(s) Covered By Program
Directed To
Eligibility
insurance status and income level/assets.
Patients should have exhausted all third-party insurance, Medicaid, Product(s) Covered By Program
Eligibility
Other Program Information
provided BMS products free of charge.
complete and sign the patient-designated area of the application. Other Program Information
enrolling a patient should call the toll- delivery of medication to the physician.
EISAI INC.
CIBA PHARMACEUTICALS
(Please see Novartis Pharmaceuticals,
Name Of Program
Aricept® (donepezil HCI) Patient Assistance Program Physician Requests Should Be
PHARMACEUTICALS
Directed To
Name Of Program
Product(s) Covered By Program
Physician Requests Should Be
Directed To
Michelle Paoli
DuPont Pharmaceuticals Company
Chestnut Run Plaza,
Hickory Run Bldg.
974 Centre Road
Wilmington, DE 19805
(800) 474-2762
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 7 Eligibility
Eligibility
through either public or privateinsurance. Aricept® will be provided Other Program Information
must provide the following to AthenaRx Home Pharmacy: a letter of denial Patient’s annual income must fall within supply. Once the request is approved, the product will be shipped quarterly to Other Program Information
ELAN PHARMACEUTICALS,
FUJISAWA HEALTHCARE,
Name Of Program
Name of Program
Physician Requests Should Be
Physician Requests Should Be
Directed To
Directed To
Product(s) Covered By Program
Product(s) Covered By Program
Permax® (pergolide mesylate),Zanaflex® (tizanadine hydrochloride),Diastat® (diazepam rectal gel),Mysoline® (primidone), Naprelan® (naproxen sodium) 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 8 Eligibility
Product(s) Covered By Program
help improve access to oral Prograf™ for program, patients must meet incomeand insurance criteria set by Fujisawa Eligibility
applications is provided by the physician Activase® is provided by the hospital.
Required information for Rituxan™ is Other Program Information
provided by the prescribing physician.
annual gross income of $25,000 or less.
Once patient eligibility has been verified eligibility has been verified for Activase® used to treat the patient. Theseprograms may be subject to change.
GENENTECH, INC.
GENETICS INSTITUTE, INC.
Name Of Program
Uninsured Patient Assistance Program
Name Of Program
The BENEFIX Reimbursement and
Physician Requests Should Be
Directed To
Genentech, Inc.
Physician Requests Should Be
Directed To
S. San Francisco, CA 94083-2586(800) 879-4747, (415) 225-1366 (fax) Product(s) Covered By Program
Benefix™ Coagulation Factor IX
(recombinant)
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 9 Eligibility
GENZYME CORPORATION
Name Of Program
temporary assistance to patients whomeet the pre-determined eligibility Established by the Genzyme Charitable the eligibility criteria are eligible for a Physician Requests Should Be
Directed To
Other Program Information
Product(s) Covered By Program
returning to the program at 1101 King Street, Suite 600, Alexandria, Eligibility
Based on financial and medical need.
Name Of Program
financial means to purchase the drug.
In order to maintain eligibility, patients Physician Requests Should Be
Directed To
Management Specialist. These optionsinclude private insurance, government Product(s) Covered By Program
Other Program Information
Eligibility
patients who have limited financialresources.
GILEAD SCIENCES, INC.
Other Program Information
Name Of Program
assistance to physicians, nurses, officemanagers, pharmacists and patients Physician Requests Should Be
Directed To
as information on billing and coding.
and provide support in challenging claim denials.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 10 Product(s) Covered By Program
Product(s) Covered By Program
Eligibility
Eligibility
result of an inability to pay. The Patient Other Program Information
designed as an interim solution to assist insurance claims assistance, referrals for until alternative funding can be found.
physicians to offer appeal procedures.
Assistance Program is considered thepayer of last resort.
GLAXO WELLCOME
Other Program Information
Name Of Program
be reviewed against the company’sestablished criteria on a case-by-case Physician Requests Should Be
Directed To
drug therapy with nominal copayments.
Additional Program Information Can BeFound At:www.glaxowellcome.com/papProgram materials may also be ordered byhealth professionals through this website.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 11 HOECHST MARION
JANSSEN PHARMACEUTICA
ROUSSEL, INC.
Name of Program
Name Of Program
Physician Requests Should Be
Physician Requests Should Be
Directed To
Directed To
Product(s) Covered By Program
Janssen’s medical prescription products
Product(s) Covered By Program
All prescription products manufactured
Eligibility
Program will ensure that all of Janssen’s prescription products [Duragesic®(fentanyl transdermal), Ergamisol® Eligibility
residents, fall below the federal poverty necessary to obtain treatment.
Reimbursement specialist determines Other Program Information
month supply of product is availableat any one time.
Other Program Information
One or two months’ supply available;
Name Of Program
The Anzement Patient AssistanceProgram and the Anzement Name Of Program
The Risperdal Patient AssistanceProgram and The Risperdal Physician Requests Should Be
Directed To
Anzement Patient Assistance Program
c/o Comprehensive Reimbursement
Consultants (CRC)
8990 Springbrook Drive, Suite 200
Minneapolis, MN 55433
(888) 259-2219
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 12 Physician Requests Should Be
Eligibility
Directed To
Program4828 Parkway Plaza Blvd., Suite 220 Other Program Information
basis. Prescription is required for every Eligibility
LEDERLE LABORATORIES
Program will ensure that allRISPERDAL® (risperidone) is made who meet specific medical criteria andlack financial resources and third-party ELI LILLY AND COMPANY
insurance necessary to obtaintreatment. Reimbursement specialist Name Of Program
determines eligibility for each patient.
Janssen requests that physicians notcharge patients beyond insurance Physician Requests Should Be
Directed To
Lilly Cares Program Administrator
physicians’ and patients’ questions and reimbursement as efficiently andquickly as possible.
Product(s) Covered By Program
Most Lilly prescription products and
KNOLL PHARMACEUTICAL
are covered by this program. Gemzar® iscovered under a separate program.
Name Of Program
Eligibility
Physician Requests Should Be
Directed To
based on the patient’s inability to pay Medicaid, government-subsidizedclinics, and other government, Product(s) Covered By Program
Medications are provided directly to the 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 13 physician for dispensing to the patient.
THE LIPOSOME COMPANY,
type of product being prescribed. AllLilly medications must be used as Name Of Program
Other Program Information
Forms to qualify a patient for the
Physician Requests Should Be
Directed To
patient’s ineligibility for other forms Product(s) Covered By Program
Eligibility
program, i.e., Medicaid, local or federalagency programs, Blue Cross/Blue Shield, private insurance programs andprivate foundations), and are unable to Name Of Program
Eligibility is determined by The Liposome Company based on Physician Requests Should Be
Directed To
Other Program Information
Product(s) Covered By Program
from a hospital, physician, or homehealth care company for a medically Eligibility
available by calling the toll-free Gemzar criteria will be approved on the basis of insurance, and ineligible for anyprograms with a drug benefit provision,including Medicaid, third-partyinsurance, Medicare, and all otherprograms have denied coverage forGemzar in writing, and all appeals havebeen exhausted.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 14 MERCK & CO., INC.
medication(s) is sent directly to theprescriber’s office for distribution to Name Of Program
Physician Requests Should Be
Directed To
The Merck Patient Assistance
Name Of Program
Product(s) Covered By Program
Physician Requests Should Be
Directed To
Product(s) Covered By Program
Eligibility
Eligibility
is designed to provide temporaryassistance to patients who have no prescription medications and are truly U.S. treating physician. All applications are reviewed on a case-by-case basis.
office for distribution to the patient.
Medicine is labeled for the patient.
Other Program Information
NOVARTIS
PHARMACEUTICALS
Each application must be completelyfilled out and signed by both the Name Of Program
mailed with an original, signed, datedprescription with the prescriber’s name, Physician Requests Should Be
Directed To
for eligibility on a case-by-case basis.
Once eligibility has been verified, up to 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 15 Product(s) Covered By Program
Eligibility
to any persons who meet specificmedical criteria and lack financial Eligibility
hardship and who have no prescriptiondrug insurance, until alternative sources Other Program Information
Patient eligibility application forms are along with their physicians and return it determine if a patient is eligible toenroll in the program or is eligible for Other Program Information
case-by-case basis. Novartis Pharma-ceuticals will be launching a new ORTHO DERMATOLOGICAL
Patient Assistance Program in January1998. Please call for information Name Of Program
ORTHO BIOTECH INC.
Physician Requests Should Be
Directed To
Name Of Program
Assistance ProgramOrtho-McNeil Patient Assistance Physician Requests Should Be
Directed To
Product(s) Covered By Program
according to approved labeledindications and dosage regimens.
Product(s) Covered By Program
PROCRIT® (Epoetin alfa) for non-
Eligibility
coverage for prescription medication.
Patients should not be eligible for othersources of drug coverage; they need tohave applied to public sector programsand been denied. Patients’ income fallsbelow poverty level and retail purchasewould cause hardship.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 16 Other Program Information
Physician Requests Should Be
Directed To
Product(s) Covered By Program
ORTHO-McNEIL
PHARMACEUTICAL, INC.
Accupril, Cognex, Dilantin, Loestrin,Neurontin, Rezulin, and Zarontin Name Of Program
Eligibility
Physician Requests Should Be
Directed To
Other Program Information
Product(s) Covered By Program
supply will be delivered to thephysician for dispensing to the patient. Eligibility
Patients should not have insurance
coverage for prescription medication.
Name Of Program
Patients should not be eligible for othersources of drug coverage; they need to Physician Requests Should Be
and been denied. Patients’ income falls Directed To
Other Program Information
Product(s) Covered By Program
and dated prescription. Medication willbe sent to the health care practitioner Eligibility
Patients must not be eligible for othersources of drug coverage and must be PARKE-DAVIS
company guidelines and physiciancertification.
Name Of Program
Parke-Davis Patient Assistance Program
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 17 Other Program Information
Other Program Information
should be mailed to the address above.
needed for patient (in mL) as well as the number of doses of IMOVAX® PASTEUR MÉRIEUX
CONNAUGHT
and weight.
TheraCys®—Six doses are provided for Name Of Program
Connaught does provide, under theprogram, for a full course of therapy— Physician Requests Should Be
Directed To
Swiftwater, PA 18370-0187(800)-VACCINE (800-822-2463) PFIZER INC
Product(s) Covered By Program
Name Of Program
IMOGAM® Rabies-HT, rabies immuneglobulin (human) (USP); TheraCys® Physician Requests Should Be
Directed To
Eligibility
Determined on a case-by-case basis.
Limited to those individuals who have Product(s) Covered By Program
patient’s household income is belowfederal poverty guidelines. Physician Eligibility
will not be sold, traded, or used for any receiving or be eligible for third-party orMedicaid reimbursements formedications. No copayment or cost-sharing is required by the patient.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 18 Other Program Information
Other Program Information
her letterhead to Pfizer stating that the Specialist. The specialist will then send Zithromax® the patient will require.
weeks to receive the product. Refillsare obtained through physician day the form is received. A letter will besent notifying the physician of the patient’s eligibility or ineligibility. It may take up to three weeks from the Name Of Program
placement of the first call to the delivery reserves the right to limit enrollment of patients.
Physician Requests Should Be
Directed To
Diflucan® and Zithromax® PatientAssistance Program Name Of Program
Product(s) Covered By Program
Requests Should Be Directed To
235 E. 42nd StreetNew York, NY 10017-5755 Eligibility
Patient must not have insurance or otherthird-party coverage, including Product(s) Covered By Program
state’s AIDS drug assistance program.
Patient must have an income of less than Eligibility
The program, a joint effort of Pfizer, the National Governors’ Association, and the National Association of CommunityHealth Centers, works solely throughcommunity, migrant, and homelesshealth centers that are funded under section 330(e), 330(g), or 330(h) of thePublic Health Service Act and that havean in-house pharmacy. The program 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 19 Eligibility
Must be an Arkansas resident to qualify.
Eligible individuals are certified by the insurance benefits and do not qualify for any government entitlement programs.
poverty level. Pfizer reserves the right to must waive his or her fee for the initial Other Program Information
Other Program Information
Physicians should contact the ArkansasHealth Care Access Foundation for Name Of Program
Aricept® Patient Assistance Program(Please see Eisai Inc. on page 6 for Name Of Program
(A Participant in) the Kentucky HealthCare Access Program Physician Requests Should Be
Name Of Program
Directed To
Health Kentucky, Inc.
12700 Shelbyville Road Name Of Program
(800) 633-8100, (502) 254-4214 (502) 254-5117 (fax) Product(s) Covered By Program
Physician Requests Should Be
Directed To
Most Pfizer prescription products arecovered Ms. Pat Keller Program DirectorArkansas Health Care AccessFoundationP.O. Box 56248Little Rock, AR 72215(800) 950-8233, (501) 221-3033 Product(s) Covered By Program
Most Pfizer prescription products are
covered
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 20 Eligibility
PHARMACIA & UPJOHN,
Must be a Kentucky resident to qualify.
Eligible individuals are certified by the Name Of Program
Kentucky Cabinet for Health Servicesas Kentuckians below the federal Physician Requests Should Be
Directed To
programs. No copayment or cost-sharingis required from the patient. Physician Other Program Information
Product(s) Covered By Program
Kentucky, Inc. for further information.
Eligibility
Based on federal poverty level and noprescription drug coverage.
Name Of Program
Other Program Information
Physician Requests Should Be
Directed To
Mr. Ken Trogdon
PROCTER & GAMBLE
PHARMACEUTICALS, INC.
Physician Requests Should Be
Directed To
Procter & Gamble Pharmaceuticals,Inc.
Product(s) Covered By Program
Attn: Customer Service Department(800) 448-4878 Eligibility
Eligible individuals must be South
Product(s) Covered By Program
by any government entitlementprograms. No copayment or cost-sharingis required from the patient. Physicianmust waive his or her fee.
Other Program Information
Physicians should contact Commun-I-
Care for further information.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 21 Eligibility
Physician Requests Should Be
Directed To
patients have full access to its products.
for patients who fall below the federalpoverty level and have no other Product(s) Covered By Program
Eligibility
case-by-case basis. A patient is eligible medical and financial need forassistance as identified by a physician, social agent or agency, and if the effort to obtain assistance from all third-party payers, Medicaid, Medicare, and otherlocal, state or federal government Other Program Information
physician is requested to fill out a form screened to ensure continued eligibility.
Other Program Information
RHÔNE-POULENC RORER
patient require an additionalprescription and completion of the Name Of Program
Patient Assistance Form forconfirmation that the patient’s status not acceptable. This program willcontinue to be reviewed andmodifications will be made to meet the changes occurring in the health careenvironment as related to the needs ofindigent patients.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 22 ROCHE LABORATORIES,
Other Program Information
A Division of Hoffmann-La Roche Inc.
Department are required. Applicationsare provided only to licensed Name Of Program
practitioners. Physicians’ and patients’ signatures and a DEA number arerequired on the application. A new Physician Requests Should Be
Directed To
established criteria of the program.
Patients and providers may berequested to participate in Product(s) Covered By Program
a three-month supply of product willbe shipped directly to the licensed Eligibility
practitioner within two to three weeks.
The Roche Medical Needs Program isdesigned as an interim solution for Name Of Program
prescription drug coverage underprivate insurance, government-funded Physician Requests Should Be
Directed To
Roche offers the Medical NeedsProgram as a philanthropic endeavor to Product(s) Covered By Program
Roche Medical Needs Program is partof Roche’s commitment to assure access This program is for individualoutpatients who meet the Medical Needs Program criteria and is offeredthrough licensed practitioners. Theprogram is not intended for clinics,hospitals, and/or other institutions.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 23 Name Of Program
ROXANE LABORATORIES,
Name Of Program
INVIRASE® (saquinavir mesylate),CYTOVENE® (ganciclovir capsules), Physician Requests Should Be
Directed To
Physician Requests Should Be
Directed To
Product(s) Covered By Program
Product(s) Covered By Program
(morphine sulfate concentrated oralsolution) 100 mg/5 ml and 240 ml bottles; Roxicodone (oxycodone)Tablets 5 mg; Oral solution 5 mg/5 ml; Name Of Program
Eligibility
recombinant), Vesanoid® (tretinoin), and Fluorouracil Injection Product will be provided free of chargeto patients through their pharmacist, Physician Requests Should Be
Directed To
Other Program Information
Physicians should call the toll-freenumber to discuss their patient’s Product(s) Covered By Program
eligibility with a program representative.
eligibility requirements, a Qualification Form will be mailed to the physician. If eligible, patients can obtain their Duraclon, Marinol®, OramorphSR®, Roxanol™, Roxicodone, orViramune® therapies through aparticipating pharmacy.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 24 SANDOZ PHARMACEUTICAL
SCHERING
CORPORATION
LABORATORIES/KEY
PHARMACEUTICALS
(Please see Novartis Pharmaceuticals, page 14).
Name Of Program
Commitment to Care
PHARMACEUTICALS
Physician Requests Should Be
Directed To
Name Of Program
Physician Requests Should Be
Directed To
Product(s) Covered By Program
Product(s) Covered By Program
Aralen,® Breonesin,® Danocrine,®Drisdol®, Hytakerol,® Mytelase,® Eligibility
ment and who cannot afford treatment.
Patient eligibility is determined on a Other Program Information
behalf of a patient. An application issent to the physician’s office for Other Program Information
directly to the physician’s office fromthe distribution center, inapproximately four to six weeks. Eachphysician is allowed to enroll sixpatients per year. Each patient canreceive a 3-month supply of medication,with an option of one refill for anadditional three months supply for atotal of six months medication for oneyear. The physician must contactSanofi’s office for the refill.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 25 Other Program Information
Name Of Program
Patients in Need® program certificatesfor free Searle medications are made Physician Requests Should Be
gives the patient the prescription for an Directed To
appropriate Searle medication alongwith a certificate for the Patients in Product(s) Covered By Program
Antihypertensives: Aldactazide®
SERONO LABORATORIES,
Name Of Program
(spironolactone), Calan® SR (verapamilHCl) sustained-release, Kerlone® Physician Requests Should Be
Antihypertensive/Anti-Anginal/Anti- Directed To
arrhythmic: Calan® (verapamil HCl),Covera-HS™ (verapamil HCl) Antiarrhythmics: Norpace® (disopyramide Prevention of NSAID-induced gastric ulcers: Product(s) Covered By Program
Eligibility
injection) for treatment of pediatricgrowth hormone deficiency The physician is the sole determinantof a patient’s eligibility for the program based on medical and economic need.
Searle provides guidelines for Name Of Program
documentation for eligibility. Theguidelines suggest that: patient suffers Physician Requests Should Be
Directed To
for prescription drugs; patient’s incomefalls below a level suggested by Searle.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 26 Product(s) Covered By Program
Fertinex™ (urofollitropin for injection, state funds, private insurance or family resources.
Name Of Program
financial information of family membersor guardians before determining the Physician Requests Should Be
Directed To
Jack Domieschel
applicants are entitled to or will begranted benefits at a later time.
Product(s) Covered By Program
Other Program Information
Serostim™ (human growth hormone[rDNA origin]) for treatment of AIDS Generally, a patient over 18 years of age may submit his or her own application.
If the patient is an adult under the SIGMA-TAU
PHARMACEUTICALS, INC.
minor, the patient and his/her guardianor parents must jointly submit an Name Of Program
application. Applications are reviewedthroughout the year. One application per patient, per year, will be accepted.
In the event of a significant change in a Physician Requests Should Be
Directed To
Name Of Program
Product(s) Covered By Program
Physician Requests Should be
Directed To
Eligibility
Product(s) Covered By Program
A patient applying for eligibility under the CDA Program must first 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 27 Eligibility
Eligibility
possible. All applicants must be a U.S.
citizen or a permanent U.S. resident.
All applicants must sign waivers and Other Program Information
release of liability forms. The patient is private insurance or family resources.
physician initiated and be submitted onan original SB Access to Care Other Program Information
application form are not acceptable.
prescribed by the treating physician.
prescribed. Reapplications are required.
Product will be sent to the requestingphysician and receipt must be verified SMITHKLINE BEECHAM
PHARMACEUTICALS
Name Of Program
Physician Requests Should Be
Directed To
Name Of Program
Physician Requests Should Be
Directed To
Product(s) Covered By Program
Product(s) Covered By Program
prescription products are covered.
Controlled substances and vaccines are are covered under separate Access toCare programs. (See listings.) Name Of Program
Access to Care Paxil Certificate
Program
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 28 Physician Requests Should Be
Eligibility
Directed To
The patient’s eligibility is determined with each prescribing physician and isbased on a patient’s inability to pay, lack Product(s) Covered By Program
Medicaid. The patient must be aresident of the United States. The PHARMACEUTICALS, INC.
or her fee. The free product must beprovided to the patient for whom it Name Of Program
Other Program Information
Physician Requests Should Be
Physicians apply on behalf of the patient Directed To
Center at (800) 788-9277. Ongoingpatient participation is available based Product(s) Covered By Program
ESTRATAB® (esterified estrogenstablets, USP) 0.3 mg (Solvay 1014); 3M PHARMACEUTICALS
ESTRATAB® (esterified estrogenstablets, USP) 0.625 mg (Solvay 1022); Name Of Program
(Solvay 1026); ESTRATEST® HS(esterified estrogens and methyl- Physician Requests Should Be
Directed To
(Solvay 4205); LUVOX® (fluvoxaminemaleate) Tablets, 100 mg (Solvay Product(s) Covered By Program
Supplement Tablets (Solvay 1148);PROMETIZIUM® Capsule SV; Eligibility
circumstances prevent them fromobtaining 3M Pharmaceuticals drugproducts considered to be necessary bytheir physicians. Consideration is on acase-by-case basis.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 29 WYETH-AYERST
Other Product Information
LABORATORIES
Name Of Program
Foundation was established to improveaccess to ENBREL® for patients who Physician Requests Should Be
Directed To
criteria set by the Foundation Board of Directors. Please call 1-800-282-7704 Product(s) Covered By Program
Name Of Program
Physician Requests Should Be
Eligibility
Directed To
Product(s) Covered By Program
Name Of Program
Eligibility
Physician Requests Should Be
Directed To
their physicians as “indigent,” meaning:a. Low or no income Other Product Information
Product(s) Covered By Program
whose patients meet the eligibilityrequirements. A three-month supply of specific products is provided directly to Eligibility
the physician for dispensing to thepatient. The patient’s signature is providers should contact 1-800-282-7704 and staff will screen patients foreligibility over the phone. If the patient appears to qualify, an application will be PHARMACEUTICALS
Eligibility criteria are subject to changewithout notice.
99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 30 99120-PhRMA PatAssist.1999 6/18/99 4:07 PM Page 31

Source: http://wteague.com/medication/DrugPatientAssitancePrograms.pdf